360 Among Patients With Posterior Communicating Artery Aneurysms and Oculomotor Nerve Palsy, Early Microsurgery is Associated With a More Rapid Cranial Palsy Resolution, While Endovascular Approaches Yield Comparable Recovery Rates in the Long Term:

INTRODUCTION: Comparing microsurgery with endovascular treatment (EVT) regarding favorable oculomotor nerve palsy (ONP) recovery outcomes in cases associated with posterior communicating artery (PComA) aneurysms has been studied extensively. however there is no consensus on the treatment timing, nuances for different patients subgroups and ONP recovery time course. METHODS: A systematic review and meta-analysis were conducted by searching PubMed, Embase, Scopus, and Web of Science databases. The extracted data included patient demographics, details on treatment modalities and timing, and characteristics of PComA aneurysms ONP caused by unruptured or ruptured aneurysms. The primary outcome was ONP favorable recovery. We used random effect models to calculate odds ratios (OR) and pool prevalence with 95% confidence intervals (CI). RESULTS: 40 studies met the inclusion criteria. Microsurgery was associated with higher rates of favorable ONP recovery outcomes in the short term follow up. After 12 months, comparable recovery outcomes were identified [18 months: (0.87 vs 0.64, P-value = 0.36); =24 months: (0.86 vs 0.72 P-Value = 0.26)] and among patients = 60 years, = 7mm aneurysms, ruptured aneurysms, and partial ONP at presentation. Delayed treatment was associated with significantly lower rates of favorable recovery, regardless of the treatment (OR: 3.04, 95% CI:2.02–4.56, P<0.01). Early window (=7 days) microsurgery or EVT were similarly associated with more favorable ONP recovery (OR= 1.65, 95% CI = 0.63 – 4.31, P= 0.31). CONCLUSIONS: Microsurgery demonstrates better recovery of ONP within the first 12 months when compared to EVT. Nevertheless, early treatment (= 7 days from presentation) and prolonged follow-up reveals comparable favorable ONP recovery outcomes between microsurgery and EVT. These results imply the necessity for tailoring treatment selection by assessing the risks and advantages on an individual basis, considering both short-term and long-term outcomes.